Other·July 29, 2022

F 689 §483.25(d) Accidents. The facility must ensure that – §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR § 72311. Nursing Service - General (a)Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 9/4/2019 at 3:47 p.m., an unannounced visit was made to the facility, to investigate an injury of unknown origin. The facility failed to provide supervision for Patient 3 with known history of self-injurious behavior and hurting others on 6/2019 and 8/2019. This deficient practice resulted in Patient 3 stabbing himself in the right eye and on his left side of neck with a ballpoint pen, and sustaining a puncture wound and bleeding on his right eye. Patient 3 was transferred to a general acute care hospital (GACH, a facility with medical staff that provides basic services not limited to medical and nursing services) for higher level of care. A review of Patient 3’s Admission Records indicated the facility admitted Patient 3 on 3/20/2019 with diagnoses that included schizoaffective disorder (a mental illness that affects moods and thoughts, and involves symptoms such as hearing voices, disorganized thinking, and periods of depression [abnormal mood]). A review of Patient 3’s Minimum Data Set (MDS, a standardized health status assessment and care screening tool) dated 6/18/2019, indicated Patient 3 experienced hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that is not real), delusions (a fixed false belief that is resistant to reason) and had behaviors of scratching and hitting self that occurred daily. The MDS indicated Patient 3 felt down, depressed, hopeless, and felt bad about self for two to six days over the last two weeks. A review of Patient 3's Physician Order dated 3/20/2019, indicated Patient 3 was being monitored every shift for episodes of self- injurious behavior, related to schizoaffective disorder. A review of Patient 3’s "Quarterly Treatment Plan" notes dated 6/18/2019, indicated Patient 3's psychosocial relationships/socialization included suicidal (deeply unhappy or depressed and likely to commit suicide) ideations and self-injurious behavior. A review of Patient 3’s "Inter-disciplinary Progress Notes" dated 6/28/2019 timed 10:05 a.m., indicated the writer was at the nurses' station when Patient 3 was observed bleeding on the right and left side of his neck. The writer indicated the patient held a pen in his hand indicating the patient stabbed himself. The notes indicated the patient informed the writer that "he, patient, had done this in his room" and continued to feel suicidal. The notes timed 11:00 a.m., indicated Patient 3 had self-inflicted abrasion (scrape, tear away) to the left (L) side and superficial (on the surface) self-inflicted abrasion right (R) neck measuring 6.0 centimeters (cm) long and no bleeding. A review of Patient 3’s "Medical/Temporary Condition Care Plans" dated 6/28/2019, indicated Patient 3 sustained self-inflicted superficial puncture (to pierce or perforate, as with a pointed instrument) to the left neck, superficial abrasion to right side of neck. A review of Patient 3’s Monthly Behavior Summary" dated 6/2019, indicated Patient 3 had one suicidal ideation, felt anxious 20 times and depressed eight times. A review of Patient 3’s "Inter-disciplinary Progress Notes" dated 7/2/2019, indicated that during an interview with Patient 3 regarding attempted suicide on 6/28/2019, the patient responded that he felt depressed because his family did not visit. A review of Patient 3’s "Monthly Behavior Summary" dated 7/2019, indicated Patient 3 had one self-injurious behavior, felt anxious 10 times, and depressed five times. A review of Patient 3's care plan dated 8/27/2019 indicated Patient 3 was at risk for sudden change in behavior and or mood related to gradual dose reduction (GDR, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether). A review of Patient 3's care plan dated 8/31/2019, indicated Patient has a history of physical assaultive behavior towards staff and used a pen to stab a peer on the shoulder. The care plan indicated the psychologist to see Patient 3 for therapeutic sessions and place the Patient 3 on one to one (1:1) monitoring upon request or if behavior is displayed. A review of a Patient 3's "Physician's Order" dated 8/31/2019, indicated Patient 3 be on 1:1 monitoring for 24 hours, then every (Q) 15 minutes monitoring for 24 hours related to (R/T) assaultive behavior. A review of Patient 3's Interdisciplinary Progress Notes dated 8/31/2019 timed 10:10 p.m., indicated Patient 3 verbalized that "I stabbed him." A room change was conducted for Patient 3. At 10:45 p.m., Patient 3 was observed bleeding from the right eye. Patient 3 stated he hurt himself in the bathroom. The same document dated 9/1/2019 timed 10:05 am, indicated Patient 3's extent of injury to the right eye was unknown and to transfer to GACH. Patient 3 recently had GDR. Patient 3 was transferred to GACH for self-abusive behavior on 9/3/2019 at 11:50 am. A review of Patient 3’s Prehospital Care Report Summary dated 8/31/2019, at 11:35 p.m., indicated Patient 3 had puncture/stab wound to right eye injury and noted with dressing, blood pressure (BP) 160/92 mmHg. Pain level 8 out of 10 (numeric pain scale zero to 10. zero no pain and 10 severe pain) during transport to GACH. A review of Patient 3’s "Staff Event Report" dated 8/31/2019 timed 10:45 p.m., indicated the following: Patient 3 was a Patient in Room 30 A staff member and Certified Nurse Assistant (CNA) 1 were on 1:1 monitoring Patients in rooms 5 and 12 A. CNA 2 heard staff calling for assistance and saw Patient 3 bleeding from right eye and neck. CNA 3 was in the hallway near Room 3, saw CNA 1 and Patient 3 walking in the hallway. Patient 3's right eye was bleeding. A review of Patient 3’s GACH records indicated Patient 3 was transferred to the emergency room on 8/31/2019 at 11:45 p.m., by ambulance. Patient 3 sustained a right scleral laceration (cut on the surface of the eye) and superficial (surface) punctures to the skin on the left neck. A review of Patient 3’s GACH's Trauma History and Physical dated 8/31/2019 timed 11:48 p.m., indicated Patient 3 stabbed himself in the neck and near eye with a ball point, and complaining of (c/o) of minor neck pain. The plan was to repair the wounds to the face, computerized tomography (CT, a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body) head r/o head injury) angiography (CTA, medical test that combines a CT scan with an injection of a special dye to produce pictures of blood vessels and tissues in a part of your body of neck r/o vascular (blood vessel) injury and computerized tomography head r/o head injury. Impression of CTA neck and CT head were unremarkable. A review of Patient 3’s GACH's emergency doctor’s (ED) Note Physician dated 9/1/2019 timed 00:36 am., indicated Patient 3 was level 1 trauma with stab wound to right eye/left neck. Patient 3 was diagnosed with ocular (eye) trauma of right eye and at risk for intentional self -harm. On 9/4/2019 at 5:10 p.m., during an interview, CNA 1 stated that on 8/31/2019 at approximately 10:45 p.m., the facility monitored Patient 3 after a physical altercation with a peer. The facility allowed Patient 3 to go inside the restroom alone and close the door. After a few minutes, Patient 3 opened the restroom door and was observed to have blood on his right eye and on the left neck. CNA1 further stated 1:1 monitoring means that the staff assigned to a Patient on 1:1 monitoring must always remain with the patient. CNA1 stated staff is required to stand at the door when the patient goes inside a restroom for as long as patient is on suicide precautions. During an interview on 9/4/2019 at 5:27 p.m., CNA 3 stated Patients 3 and 4 were roommates. CNA 2 stated she was monitoring another room when she heard a commotion (noisy disturbance) coming from Patients 3 and 4's room, ran to the room and saw Patients 3 and 4 on the ground. Patient 4 had his hand up like Patient 3 was about to stab Patient 4. CNA 2 stated she heard Patient 4 say Patient 3 tried to stab him. CNA 3 stated Patient 3 had a blue ball point pen and tried to stab CNA 1 when CNA 1 attempted to stop Patient 3 from stabbing anyone with the ball point pen. CNA 2 stated the blue point pen appeared to have blood on it. CNA 2 stated the facility did not conduct a body check on Patient 3 after the Patient attempted to stab CNA 1. CNA 2 stated the facility permitted Patients to have pens in their rooms and that pens are not contrabands (any item that is illegal to possess). A review of the facility's report dated 9/5/2019 indicated Patient 3 stabbed himself in the right eye with a pen on 8/31/2019, and that the pen was removed from the patient and placed at the nursing station. The document further indicated Patient 3 assaulted his roommate with the same pen Patient 3 used to stab himself. On 9/18/2019 at 2:09 p.m., during an interview Director of Nursing (DON) stated patient who are not on suicide precaution have the right to go inside the restroom unattended. The DON further stated Patient 3 was allowed to have a ballpoint pen unsupervised as ballpoint pens were provided by the facility for patient’s use. A review of an undated facility policy titled "Contraband Policy," indicated sharp objects of any kind, including but not limited to scissors, nail files, letter openers, pencils, etc., were not allowed in patient's possession. A review of undated facility policy, titled "One to One Observation," indicated during one -to- one observation (1:1), patient is to be no further than arms distance from staff person at all times. A review of facility undated policy and procedure titled "Q 15 Monitoring," indicated a client may be placed on Q15 minutes checks for the following reasons, but not limited to medical conditions, absent without leave (AWOL) precautions, assaultive behavior, suicide precautions or other risk behaviors. The facility failed to provide supervision for Patient 3 with known history of self-injurious behavior and hurting others. This deficient practice resulted Patient 3 stabbed himself in the right eye and on his left side of neck with a ballpoint pen, and sustaining a puncture wound and bleeding on his right eye. Patient 3 was transferred to a general acute care hospital for higher level of care. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of all Patients in the facility.